A. Summary

1. Hemorrhoids
2. Infections (Proctitis)
3. Pruritis Ani
4. Anal Fissure
5. Solitary Rectal Ulcer
6. Rectal Prolapse
7. Anal Fistula - mainly Crohn's Disease
8. Fecal Incontinence
9. Risk factors include low fiber diet, anal sex, mutliple sex partners, HIV infection
10. Proctitis in AIDS discussed below

B. Anorectal Examination

1. Includes perianal region and 2-5cm into rectum
2. Careful examination of masses with anoscopy is required [1]

C. Infections (Proctitis)

1. Herpetic Proctitis
   1. Persons who participate in receptive anal intercourse
   2. Majority of cases due to herpes simplex virus Type 2
   3. Present with fever, severe anorectal pain, tenesmus
   4. Difficulty initiating urination and sacral dermatome paresthesias also common
   5. Perianal ulcers occur in ~70% of cases
   6. Inguinal lymphadenopathy is common
   7. Mucosal friability and ulcers in distal 5-10 cm of the rectum on sigmoidoscopy
   8. Multinucleated giant cells on examination of rectal tissue
2. Anal Condylomata Acuminata [9]
   1. Genital warts caused by human papilloma virus (HPV)
   2. Anal intercourse is a risk factor
   3. However, majority of patients with condylomata have not engaged in anal intercourse
   4. Soaking lesion in 3-5% acetic acid (vinegar) will turn warty tissue white
   5. Detection of one lesion should prompt thorough exam for other lesions
   6. Trichloracetic acid (TCA) 85% applied to the lesion has 80% efficacy
   7. Cryotherapy with liquid nitrogen also effective, but several treatments needed
   8. Interferon and topical fluorouracil (Efudex®) are also useful
   9. Imiquimod (Aldara®) or podofilox (Condylox®) can also be used
   10. Long term infection with HPV in anal region is a risk factor for anal cancer
3. Lymphogranuloma venereum
   1. Caused by one of the three serotypes of Chlamydia trachomatis
   2. The papule ulcerates and causes pain, symptoms of proctitis
4. Gonococcal Proctitis
5. Syphilis
6. Crohn's Disease can also cause proctitis
7. Abscess [9]
   1. Begin as infection in anal glands
   2. Usually presents in the anal verge as a perianal abscess (easily drained)
   3. Infection may track through internal and external sphincters into ischiorectal space
   4. These ischiorectal space abscesses are more difficult to diagnose and more serious
8. Cryptitis [9]
   1. Localized infection in one of the anal glands
   2. Unusual condition presents as pearl of pus beading up from crypt of level of dentate line

D. Radiation Proctitis

1. Associated with radiation given for malignant pelvic disease
2. Risk of chronic proctitis 5-20% 5 years within radiation therapy
3. Higher incidence of acute radiation proctitis which is usually self limited
4. Topical glucocorticoids and sucralfate have been used with minimal efficacy
5. Butyrate stimulates vasodilation, mucosal proliferation and mucosal repair
6. Topical butyrate improves symptoms and healing rates in acute radiation proctitis [8]

E. Pruritis Ani

1. Means pruritic (itching) skin in anal region, which is particularly sensitive
2. Causes include allergies, infections, dermatologic disorders, cancers, idiopathic
3. Poor hygiene or overzealous attempts to clean rectal area are major causes
4. Infections
   1. Bacterial
   2. Fungal
   3. Parasitic - uncommon except for pinworms (Enterobius vermicularis)
5. Dermatologic Syndromes: psoriasis
6. Cancers: anal carcinoma, Kaposi Sarcoma
7. Itch - scratch cycle often becomes self-propagating (often during sleep)
8. Treatment
   1. Recognize and treat underlying causes
   2. Antihistamines (first generation) are often beneficial, particularly before bed
   3. Topical glucocorticoids are often helpful to control itching
   4. Topical xylocaine (lidocaine) ointment can also reduce itching
   5. Pruritic lesions that persist after treatment should be biopsied

F. Anal Fissure [9]

1. Defined as small cut or split in anoderm
2. Unclear etiology
   1. May be related to repetative trauma to region
   2. Possibly due to ischemia of posterior commissure of anal canal
   3. Severe constipation may precipitate fissures [6]
   4. Lateral fissures usually suggest infectious rather than physical etiology
3. Symptoms
   1. Pain on defecation
   2. Rectal bleeding
   3. Spasm of internal anal sphincter
   4. Chronic anal sphincters (>3 months) may present with external anal tag
4. Differential diagnosis as above
5. Treatment
   1. Initiating treatment within 3 months of initial fissure associated with better outcome
   2. Local suppositories containing anesthetic (such as lidocaine) with glucocorticoids
   3. Infectious causes must be treated aggressively to allow healing
   4. Topical xylocaine (Lidocaine® as above) 5%
   5. Glycerol trinitrate (nitroglycerin) 0.2% ointment
   6. Botulinum toxin appears very effective for relaxing muscle and healing fissures [3]
   7. Botulinum toxin appears to be more effective than topical nitroglycerin [7]
   8. Surgical: anal dilitation, sphincterotomy (incontinance rate ~30%)

G. Solitary Rectal Ulcer Syndrome

1. Chronic benign condition associated with rectal prolapse
2. Single or multiple lesions surrounded by hyperemic margins
3. Lesions often olucerated or polypoidal
4. Typically on anterior or anterolateral rectal wall
5. Likely from repeated trauma of rectal mucosa against puborectalis muscle contraction
6. Usually present with rectal bleeding, tenesmus, straining with defecation
7. Diagnosis with sigmoidoscopy and histologic examination
8. Treatment usually includes high fiber diet; severe cases may benefit from surgery
9. Routine sigmoidoscopic followup for healing is recommended

H. Fecal Incontinance [2,4,5,11]

1. Involuntary loss of rectal contents through anal canal
2. Devastating nonfatal illness causing anxiety and embarrassment
3. Epidemilogy
   1. Overall prevalance ~2% in USA, up to 50% of nursing home patients
   2. ~30% >65 years old, ~60% female
4. Causes (Panel, Ref [11])
   1. Congenital
   2. Anatomic
   3. Neurological
   4. Functional
5. Congenital Causes
   1. Imperforate anus
   2. Rectal agenesis
   3. Cloacal defects
   4. Myelomeningocele
   5. Meningocele
6. Anatomic
   1. Obstetric injury, vaginal delivery
   2. Anorectal surgery
   3. Sphincter-sparing bowel resection
   4. Pelvic fracture
   5. Anal impairment
7. Neurological
   1. Diabetes mellitus
   2. Multiple sclerosis
   3. Stroke
   4. Dementia
   5. Central nervous system: tumor, infection, trauma
   6. Spina bifida
   7. Pudendal neuropathy
8. Functional
   1. Psychiatric disorder
   2. Rectal intussusception, prolapse
   3. Fecal impaction
   4. Physical disabilities
   5. Various causes of diarrhea: malabsorption, IBD, radiation proctitis, hypersecretory tumor
9. Fecal urgency with incontinence (rectal hypersensitivity) may be due to elevated levels of heat and capsaicin receptor vanilloid receptor 1 (TRPV1 or VR1) [10]
10. Evaluation
    1. History and physical to assess causes above
    2. If diarrhea present, it should be treated first
    3. Anorectal physiology testing if no diarrhea or persistent incontinence
11. Treatment Overview [11]
    1. If no sphincter defect, biofeedback
    2. If major sphincter defect, overlapping sphincteroplasty
    3. If sphincteroplasty fails and persistent sphincter defect, consider repeat or other modality
    4. Other modalities includes dynamic graciloplasty, artificial sphincter, sacral stimulation
    5. Sacral spinal stimulation may be effective with functionally deficient but morphologically intact anal sphincter [12]
    6. An artificial anal sphincter with reasonably good success has been developed
    7. Ostomy is generally last resort

I. Rectal Bleeding [1]

1. Most commonly caused by hemorrhoids, fissures and polyps
2. However, colon cancer and other serious causes must be ruled out
3. Should distinguish between bright red blood and occult blood

J. Proctitis in AIDS [13]

1. Infectious causes most common
2. In homosexual men having anal intercourse, gonorrhea, herpes simplex, chlamydia (including lymphogranuloma venereum), and syphilis are most common (in decreasing order)
3. Some overlap of proctitis with infectious colitis due to E. coli, Clostridium difficile, shigella, salmonella, amoeba
4. Cytomegalovirus and mycobacterium also occur
5. Non-infectious causes include ischemic proctitis (uncommon), inflammatory bowel disease (IBD), radiation induced proctitis

References

1. Pfenninger JL and Zainea GG. 2001. Am Fam Phys. 63(12):2391
2. Wald A. 2007. NEJM. 356(16):1649
3. Maria G, Cassetta E, Gui D, et al. 1998. NEJM. 338(4):217
4. Tariq SH, Morley JE, Prather CM. 2003. Am J Med. 115(3):217
5. Landefeld CS, Bowers BJ, Feld AD, et al. 2008. Ann Intern Med. 148(6):449
6. Iacono G, Cavataio F, Montalto G, et al. 1998. NEJM. 339(16):1100
7. Brisinda G, Maria G, Bentivoglio AR, et al. 1999. NEJM. 341(2):65
8. Vernia P, Fracasso PL, Casale V, et al. 2000. Lancet. 356(9237):1232
9. Pfenninger JL and Zainea GG. 2001. Am Fam Phys. 64(1):77
10. Chan CLH, Facer P, Davis JB, et al. 2003. Lancet. 361(9355):385
11. Madoff RD, Parker SC, Varma MG, Lowry AC. 2004. Lancet. 364(9434):623
12. Matzel KE, Kamm MA, Stosser M, et al. 2004. Lancet. 363(9417):1270
13. Davis BT, Thiim M, Zukerberg LR. 2006. NEJM. 354(3):284 (Case Record)